Key Policy Issue #1: Estimating the costs of scaling up and their affordability

The Taskforce on Innovative International Financing for Health Systems estimated that nine per cent of the total costs of scaling up health systems were related to pre-service training of health workers (WHO, 2009). The Lancet Commission estimated current global spending in education and training of health professionals at 100 billion US dollars, or less than two per cent of total health expenditure. The Commission described this level of investment as “not only insufficient but unwise, putting the remaining 98% at risk.” (Frenk, et al., 2010:35.) If two per cent is not enough, the question arises of how much should a country spend?

Producing more health workers requires more training, strategic marketing and recruiting, remunerating more educators and trainers, and additional infrastructure (laboratories, classrooms, dormitories) financial resources and equipment. There are two categories of costs that need to be considered in planning the expansion of the health workforce. First, there are the costs of expanding training capacity, which are a mix of capital costs for additional infrastructure and equipment, and recurrent costs for staff salaries and operating costs. Second, there are the costs associated with the employment of an expanded workforce, which are largely recurrent. The high proportion of recurrent costs which are part of the total costs of scaling up presents a problem for low-income countries dependent on external aid, since donors are generally reluctant to take on long-term financing commitments.

The affordability of additional expenditures generated by the scaling up is a matter for political decision based on value choices as well as on economic criteria, and consideration of the benefits in terms of health outcomes. Spending more on the education of health professionals would be acceptable if addressing the health needs of the population were considered a priority. There are strong arguments to do so, as evidence shows that the strengthening of health systems to make them more effective in tackling population needs, namely through stronger primary care services, leads to better health outcomes and to economic development (Commission on Social Determinants of Health, 2012; Figueras and McKee, 2012; McKee, Basu and Stuckler, 2012). However, care is needed to ensure that the fiscal space is sufficient to cover the new expenditures, which raises the second issue.